University Student Mental Health: An Important Window of Opportunity for Prevention and Early Intervention

The opportunity: The transition to university marks a critical period for psychological, sociological, and biological development. This is a time when many young people leave home, take on more responsibility for their lifestyle choices (i.e., substance use, sleep schedule) and time management, make new friends, and learn about themselves in a broader sociocultural context; all whilst adjusting to a new learning environment and striving to meet higher education standards. ¹ At the same time, the brain is undergoing accelerated growth and development, and the prefrontal cortex, responsible for making good decisions with a full appreciation of the context and consequences, remains very much a work in progress. ² Entry to university also coincides with the peak period of risk for the onset of mental disorders and addictions, which if unrecognized and untreated, can lead to persistent and refractory illness, comorbidity, school drop-out, diminished quality of life, and reduced life expectancy ³ Taken together, higher education provides an important window of opportunity to support young people in developing healthy socioemotional coping resources and to identify and treat emergent mental disorders, helping young people to reach their full potential and laying a foundation to support well-being lifelong. ⁴

The challenge: Compared to any previous generation, young people now (especially females) are more likely to suffer from common mental disorders such as anxiety and depression and engage in self-harm.^5,6 As universities increase enrolment in terms of the total numbers and diversity of students, the population increasingly resembles the general population of young people. For example, increases in anxiety, depression, self-harm, and suicide have been documented in university students in the UK, mirroring similar trends in the general population. ⁷ Taken together with efforts to destigmatize mental health, it is therefore not surprising that universities are experiencing an unprecedented increased demand for student mental health support and learning accommodations related to mental health conditions, outpacing increases in enrolment and straining university resources.^1,8 University students today experience unique pressures including increased academic standards, competition for relatively fewer opportunities, and more financial stress, against a backdrop of uncertain global economic and geopolitical climates and rising concern about the sustainability of the planet. In addition to early risk exposures such as childhood adversity (i.e., early loss, abuse, and neglect), family factors (i.e., attachment, functioning, and socioeconomic status), and prior mental illness, more proximal risk factors such as substance misuse, social isolation or exclusion, perfectionism, and perceived failure (often for the first time) are associated with poor student mental health and increased risk of suicide.^9,10

Therefore, the importance of providing a safe, welcoming, and compassionate learning environment is paramount to student well-being and universities are working to support their students through changes across organizational structures and processes, as well as in mindful curriculum design. Recently a Canadian National Standard ¹¹ was published, outlining a set of guiding principles for the development of postsecondary student wellness services based on the socioecological and dual continuum models of mental health and well-being; namely highlighting the importance that such services be student-centred, support equity, diversity, and inclusivity, be informed by evidence, focus on health promotion and harm reduction, foster connectedness to the broader learning community, and strive for continuous improvement through research. At the same time, there is increasing recognition that universities have an important role to play in developing accessible and effective student mental health support focused on prevention and early intervention with facilitated transitions to more specialized community mental health services when needed.^1,12 This is especially important given that university students have concentrated academic terms, are typically transient (moving between home and campus), and often present with problems below clinical thresholds for community mental health services, which focus on acute or chronic severe mental illness and have long waitlists. Authoritative papers, standards, and reviews all point to the need for large-scale, longitudinal data collected using rigorous research methods to accurately estimate the student mental health burden and inform the development and continued improvement of coordinated evidence-based interventions (universal and targeted) delivered as part of an overarching framework and guided by a whole university approach and stepped care model^1,8

This Issue: This special issue in the Canadian Journal of Psychiatry is timely and features several original research papers that address some of the identified knowledge gaps related to university student mental health. The U-Flourish Student Mental Health Research program was launched in 2018 ¹³ as a collaboration between academics, clinicians, campus stakeholders, funders, and importantly in copartnership with students. As part of this work, each year a new cohort of students are invited to join a digital conversation at entry to university that continues over the course of their undergraduate studies in the form of the U-Flourish Student Well-Being Survey. ⁹ The resulting large-scale, longitudinal data has made it possible to track student well-being and mental health outcomes within individuals and across cohorts using validated measures, evaluate barriers and access to mental health care, as well as examine the contribution of theoretically important risk and protective factors.^14‐16 In this issue, King et al. report on the Canadian student mental health burden prior to and over the different phases of the COVID-19 pandemic. In line with studies globally, increases in clinically significant symptoms of common mental disorders (especially in female students) were reported up to the peak phase of the pandemic, that on subsequent follow-up have improved somewhat but not returned to prepandemic levels. The pandemic was associated with a negative impact on student well-being and social relationships, the quality of their learning experience, and their optimism about future prospects. This longitudinal data from large representative samples of students will inform the planning and development of student-tailored, accessible and engaging mental health support moving forward.

Bhattarai et al., also using longitudinal data from the U-Flourish Student Well-Being Survey, explored the association between early childhood adversity including parental loss, physical and sexual abuse, and peer bullying and student mental health problems over the first year at university. Importantly, early adversity was negatively related to mental health through an association with increased stress-sensitivity, lower self-esteem, and reduced sleep quality. Implications of these findings include that stress coping mechanisms, self-esteem, and improving sleep may be important prevention and early intervention targets, informing universal mental health literacy and health promotion efforts, as well as interventions targeting higher-risk and help-seeking students.

Two additional studies in this issue used repeated cross-sectional surveys to assess trends in student perceived stress and in suicidal thoughts and behaviours (STB) over different phases of the COVID-19 pandemic. In the paper by Linden et al., students across 15 Canadian postsecondary institutions reported chronically high levels of stress across a broad range of concerns, with particularly high levels focused on academic and financial challenges. The former suggests a mindful approach to pedagogy is paramount in reducing student stress; for example, as reflected in scheduling and weighting of examinations and assignments, the provision of clear instructions, and consideration of the fact that many students are juggling working at paid jobs to support their studies.

The death of a young person is a devastating loss affecting family, friends, the university community, and broader society. While fleeting suicidal thoughts are common and usually situation-specific, identifying young people at risk for acting upon those thoughts is a recognized priority. Asking young people about whether or not they have suicidal thoughts will not increase risk and may help, providing an opportunity for signposting students to appropriate resources and important data to aid strategic planning and care pathway development to better assist distressed students. ¹⁷ In the paper by Jones et al., STB was reported to be generally stable over the pandemic, with an increase seen over the academic term that coincided with increased academic demands such as examinations and assignments. This is in line with data from the UK, in which student suicides were shown to have slightly increased over the past decade, but remain below that of the general population of young people, and with observed seasonal increases that coincided with exam-intensive periods. ¹⁸ As part of the overarching university institutional policy on mental health, Universities UK has developed guidance around implementing Suicide-Safer Universities, ¹⁹ providing a framework and strategies that are coproduced with students, parents, clinicians, faculty, and local and national stakeholders.

What can Psychiatry Contribute? This special issue draws attention to the importance of evidence-informed university student mental health promotion and prevention. To succeed this effort will need to be collaborative and involve a wide range of stakeholders including university leadership, faculty, mental health care providers on campus and in the community, local and national mental health organizations and importantly students and their families. The approach should be theoretically grounded and evidence-based combining both a whole university approach and incorporating a stepped care framework to organize and rationalize care. Psychiatry has historically played a major role in the development and provision of student mental health services in Canada post World War II. ¹ For example, in May 1963, a National Conference on student mental health was held at Queen's University in partnership with the Canadian Mental Health Association and the Canadian Union of Students and involving prominent psychiatrists working in and directing Student Mental Health Services including Dana L. Farnsworth from Harvard University.

Over time, the oversight and leadership of university student mental health services in Canada have shifted away from psychiatry and the academic Faculty of Health Sciences, nonetheless, psychiatry still has an important contribution to make. Psychiatrists are well-trained in developmental psychopathology and experts in differentiating normative distress and symptoms related to overwhelmed coping from the emergence or recurrence of more serious and persistent psychiatric illness. In this way, consulting psychiatrists can guard against overmedicalization and overdiagnosis on the one hand, and underrecognition and undertreatment of emergent psychiatric disorders on the other hand. For example, not all cases of anxiety and depression require treatment with a selective serotonin reuptake inhibitor, nor do problems concentrating equate to a clinical diagnosis of attention-deficit/hyperactivity disorder requiring stimulant medication. Further, medications when not indicated can cause harm. That said, students presenting with major mental disorders including emergent psychosis, bipolar disorder, and refractory mood and anxiety disorders would benefit from timely psychiatric assessment and specialized treatment. In most university mental health services around the globe, consulting psychiatrists work with university-based primary care and allied mental health teams and take on a major role in mental health promotion, providing clinical oversight and evidence-informed content including for student-tailored mental health literacy. ²⁰ Furthermore, the development of mental health care pathways with seamless transitions to and from more specialized community services is an acknowledged major gap and access barrier that psychiatry is uniquely well-placed to address. Finally, academic psychiatrists have an established track record of leading productive collaborative applied research translating findings into improved resources and services, and experience with embedding metrics in services for program planning, evaluation, and improvement purposes.

In summary, young people in higher education represent the future leaders of our evolving society and are at an exciting developmental stage. Effective mental health prevention and when indicated early intervention during this critical period will have benefits that extend far past graduation. The higher education setting is therefore ripe for thoughtful, collaborative, and evidence-informed efforts to ensure that all students from diverse backgrounds and with a variety of risk and protective factors reach their potential and Flourish.